Dr Febin Azeezia medical college Kollam Management and Treatment The best treatment must control the ulcers for the longest period with minimal side effects Important to rule out ID: 909142
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Slide1
Management of oral ulcers
Dr
Febin
Azeezia
medical college
Kollam
Slide2Management and Treatment
The best treatment must control the ulcers for the
longest period with minimal side effects
..
Important
to rule out
predisposing factors
The forms of therapy range from
topical application to systemic administration of drugs
, and even the newer technologies of ultrasound have been tried.
Slide3THE PRIMARY GOAL
Relief of pain
Reduction of ulcer duration
The restoration of normal oral function
Slide4SECONDARY GOAL
Reduction in the frequency and severity of recurrence
Maintenance of remission.
Slide5THE TREATMENT APPROACH
Determined by disease severity (pain)
The patient’s medical history (SYSTEMIC ILLNESS)
The frequency of flare–ups
The patient’s ability to tolerate the medication
Slide6DIETARY AND GENERAL MEASURES
No
reliable studies addressing
One should
avoid
hard, acidic and salty substances such as fruit juices, citrus fruits, tomatoes, and spices like pepper, paprika and curry, as well as alcoholic and carbonated beverages.
A recent study showed
omega 3 fatty acid
supplementation reduced symptoms
In another study –
no benefit
in use of daily multivitamin tablets
But
vitamin B12 supplementation
– duration ,number and level of pain reduced
Avoiding
dental care products with
sodium lauryl sulfate (SLS)
Maintain
good
oral hygiene
Slide7Slide8TOPICAL ANESTHETICS
LIDOCAINE
1% cream
2% gel or spray;
Polidocanol
as paste; and benzocaine lozenges
A mouth wash containing benzocaine and
cetylpyridinium
chloride
Slide9ANTISEPTICS AND ANTI-INFLAMMATORY AGENTS
Mouth wash containing
0.15%
triclosan
in ethanol and zinc sulfate
Diclofenac 3%
in a 2.5% hyaluronic acid gel was superior to a lidocaine 3% gel in reducing pain after 2–6 hours
Chlorhexidine
mouthwash reduced the frequency, increased healing speed, and decreased the severity of
aphthous
ulcers
Slide10CAUTERIZATION
Topical application of
hydrogen peroxide 0.5%
solution or silver nitrate 1–2% solution significantly reduced the
pain severity after one day, but did not increase the speed of healing .
Treatment with a CO
2
or
Nd:YAG
laser brought immediate pain relief which lasted for 4–7 days
Slide11TOPICAL TETRACYCLINE TREATMENT
Mouthwash containing
chlortetracycline 2.5%
increased the number of ulcer-free or pain-free days significantly, by 40% compared to a placebo
A mouthwash containing
tetracycline
(dissolve soluble tetracycline capsule 250 mg in 5–10 ml water and rinse)
In regards to pain reduction, a
minocycline 0.2%
mouthwash was superior to a tetracycline 0.25% mouthwash
Other antibiotics such as
aureomycin
(containing 3%chlortetracycline),
doxymycin
, minocycline(0.2% aqueous solution), penicillin G (50 mg penicillin G potassium troches) have been proven to be effective in managing these ulcers.
Slide12TOPICAL ANTI-INFLAMMATORY AGENTS:
Amlexanox
5%
paste or 2 mg tablets – (anti-allergic and anti-inflammatory activities)
when used in the prodromal stage, led to a reduction in the number and size of oral
aphthous
ulcers, as well as reduction in pain
5-aminosalicylic acid 5%
cream achieved pain reduction and more rapid healing of oral
aphthous
ulcers
Topical sucralfate
is effective in treating RAS ulcerations when administrated at 5ml, 4 times/day.
Sucralfate exerts a soothing effect on the lesions by adhering to mucous membrane tissues and forming a
protective barrier on the affected site.
Slide13TOPICAL CORTICOSTEROIDS
The combination of
topical anesthetics
during the day with an oral paste containing
triamcinolone
in the evening is also effective
Although both were equally effective in reducing pain,
dexamethasone oral paste
produced more rapid healing than triamcinolone oral paste
The paste is to be applied
2-3 times
a day. Long term use of these steroids may develop
local candidiasis
Betnesol
mouthwash is being used .
Betamethasone sodium phosphate tablet 500 mcg dissolved in 10 ml of water and used as a mouthwash for 3 min then discarded.
It is administered
four times a day
(QID) in the presence of ulcers and twice a day (BID) in between ulcer attacks.
Painful, deep ulcers can be treated
with
intralesional
triamcinolone suspension
0.1–0.5 mL per lesion
Slide14IMMUNOMODULATORY AGENTS:
Topical non-corticosteroid based immunomodulatory agents :-
Azelastine
Human alpha-2-interferon in cream
Topical cyclosporine
Topical 5-aminosalicylic acid and prostaglandin E2 (PGE2) gel
Slide15PHYSICAL THERAPY
Surgical removal, debridement or laser ablation of ulcers, low intensity ultrasound, chemical cautery
Laser therapy
–
Studies have shown that laser therapy of most
apthae
immediately relieves pain, speeds
healing, and reduces recurrence.
Silver nitrate
-changing the lesion to a burn.
Some studies revealed decreased severity of pain.
However, none have demonstrated shortened healing time.
Slide16ULTRASOUND THERAPY
Twice–daily application of low intensity medical ultrasound may have a modest beneficial effect
Slide17SYSTEMIC THERAPY
The main goals of systemic therapies are
To reduce the frequency of recurrences
To
minimise
the duration of ulcers
Slide18COLCHICINE
Colchicine (0.5–2 mg daily) is helpful for the majority of patients with chronic recurrent oral
aphthous
ulcers
Is an anti-inflammatory agent that limits leukocyte activity by binding to beta-Tubulin, a cellular
microtubular
protein, and therefore inhibiting protein polymerization.
The
aphthous
ulcers frequently recurred when the treatment was stopped
Slide19PENTOXIFYLLINE
Anti-inflammatory, immunomodulatory,
methylxanthine
derivative that blocks neutrophil adherence and is indicated for peripheral vascular disease
In case reports and older non-controlled studies, both
pentoxifylline
and
oxypentoxifylline
300 mg 1–3 times daily or 400 mg
t.I.D
.
Achieved good response rates (in children 36–50%) .
in a more recent controlled study,
pentoxifylline
(400 mg
t.I.D
.) Was only able to reduce the size of oral
aphthous
ulcers (p = 0.05)
Slide20SYSTEMIC CORTICOSTEROIDS
Systemic corticosteroids
should be considered if colchicine and
pentoxifylline
do not produce improvement
.
Prednisolone or prednisone equivalents (10–30 mg daily)
can be used on a short-term basis (up to one month) during a flare of the disease to speed healing.
In a small controlled study, prednisolone 5 mg daily for 3 months was comparable to colchicine 0.5 mg daily. It produced a clear reduction in pain, as well as in number and size of oral
aphthous
ulcers .
Prednisone (25 mg daily tapered over 2 months) was more effective than the leukotriene inhibitor
montelukast
in managing oral
aphthous
ulcers
Slide21SUCRALFATE
Sucralfate is used as an antacid in treating gastric and duodenal ulcers.
Sucralfate suspension produced more rapid healing and reduced pain of both oral and genital
aphthous
ulcers
Slide22DAPSONE
It is an
antioxidant
which exerts its effects primarily through
suppression of inflammatory cell migration
.
Dapsone
significantly
reduced the number and size
of oral and genital
aphthous
ulcers
A dose of
100–150 mg/day
can be used for oral and genital aphthae.
Haemolysis
,
methaemoglobulinemia
and agranulocytosis are serious side-effects that may occur
Slide23ANTIMETABOLITES: AZATHIOPRINE AND METHOTREXATE
In a placebo-controlled study, azathioprine reduced the frequency and severity of
orogenital
aphthous
ulcers
In a case series, methotrexate 7.5–20 mg in a single weekly dose was helpful for severe
orogenital
aphthous
ulcers
Slide24CYCLOSPORINE
Dose of
3 to 6 mg/kg/day
was found to be effective in about 50% of patients with recurrent
aphthosis
either as a monotherapy or in combination with steroids to achieve a higher
antiinflammatory
effect.
Its use is absolutely contraindicated in nursing women.
Pregnancy and renal insufficiency are considered relative contraindications.
Slide25THALIDOMIDE
Inhibits the production of various cytokines as a result of its
effects on T lymphocytes, monocytes, and
polymorphonuclear
cells and selectively
inhibits the production of TNF
.
Is considered effective against
orogenital
aphthous
ulcers.
In older open or retrospective studies, initial doses of
100–300 mg daily
were tapered to
50 mg
daily or the medication was discontinued after 3 months, in order to avoid a sensory neuropathy .
The therapy with thalidomide
(anti-
tnf
-a actions
), proved to be effective in
lowdose
of 50 mg/day
against major type of
ras
and
oro
-genital ulcers
Thalidomide should only be used in exceptional cases. Because of its teratogenicity, it is absolutely contraindicated in pregnancy .
When it is discontinued, recurrences may develop rapidly
Slide26IMMUNE ENHANCEMENT:
Levamisole
is an
immunopotentiating
agent that has demonstrated the ability to normalize the CD4+ cell/CD8+ cell ratio and improve symptoms in recurrent
aphthous
ulcers (RAU) patient
Dosage of
10-15-mg/day
for 2-3 months can reduce the pain, number, frequency and duration of ulcer.
Adverse effects like nausea, hyperemia, dyspepsia and agranulocytosis limits the use of this drug.
Slide27INTERFERON-Α
Interferon-α can achieve complete or partial remission
(reduction in pain, duration and frequency)
of recurrent
orogenital
aphthous
ulcers within 1–4 months .
A low-dose (3 million IU 3 times weekly) maintenance therapy is recommended after 6 months.
Combination therapy with corticosteroids, colchicine, or
benzathine
penicillin is possible
Slide28OTHER SYSTEMIC AGENTS
In a controlled study, sub-antimicrobial doses of
doxycycline (40 mg daily)
prolonged the interval between
aphthous
ulcers .
Zinc sulfate 300 mg
daily reduced the number and size of
aphthous
ulcers in comparison to placebo .
In patients with pre-menstrual flares of oral
aphthous
ulcers,
once yearly subcutaneous injections of testosterone
helped in some cases .
Estrogen-dominant oral contraceptives
can also be employed . An effect is first to be expected after
3 to 6 months
.
Irsogladin
: This drug used for treatment of
gastritis and peptic ulcer
studies shown that
irsogladin
when
administered orally 2 to 4 mg/day,
reduce
ulcer counts increments
and also taking it regularly
prevent the recurrent
aphthous
stomatitis
.
Apremilast
– PDE4 inhibitor also tried .
Slide29BIOLOGICS
Infliximab
- a
chimeric anti-TNF antibody
, is very effective in the management of refractory and recurrent oral and genital ulcers.
It is usually given in a dose of
5 mg/kg body
weight
intravenously
in different schemes (e.g. 2, 6 and 32 weeks after the first injection).
Efalizumab
and
Adalimumab
other biological agents - highly efficient and completely prevented the development of aphthae
Etanercept
: recombinant TNF-soluble receptor
can be used cases of recalcitrant, recurrent ulceration in a dose of
25mg subcutaneously
twice a week.
The only adverse effect reported is mild erythema, induration and tenderness at injection site.
Slide30Slide31REBAMIPIDE
Is an
amino acid
analog of 2 (1h)-
quinolinone
.
First antiulcer drug
that
increases the endogenous prostaglandins
in mucosa and
inhibits oxygen
derived
free radical production
.
Increase in blood flow
and
production of protective prostaglandins
in ulcer mucosa, which accelerates the process of healing.
Rebamipide
2-(4-chlorobenzoylamine)-3-[2-(1h)-quinolinon-4-yl] is a
new
mucoprotective
agent
which enhances
preservation of existing epithelial cells
and replacement of lost tissue through a multifactorial mode of action
Slide32Dosage
The adult dosage of
rebamipide
is
100 mg orally three times daily.
Rau: 3 tablets/day for 7-14 days.
Behcet's
disease: 3 tablets/day for 2 months.
Reduced aphthae count and decreased pain with excellent recovery by seventh day.
Slide33THANK YOU
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